Medications:

Aspirin and Other Anti-Clotting Drugs

Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either antiplatelets or anticoagulants. Appropriate anticlotting medications are started immediately in all patients. Such drugs are sometimes used along with thrombolytics, and also as on-going maintenance to prevent a heart attack. All anti-clotting therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.

Anti-Platelet Drugs. These drugs inhibit blood platelets from sticking together, and therefore help to prevent clots. Platelets are very small disc-shaped blood cells that are important for blood-clotting.

• Aspirin. Aspirin is an antiplatelet drug. An aspirin should be taken immediately after a heart attack begins. It can be either swallowed or chewed, but chewing provides more rapid benefit. If the patient has not taken an aspirin at home, it will be given at the hospital. It is then continued daily. Using aspirin for heart attack patients has been shown to reduce mortality. It is the most common anti-clotting drug, and most people with heart disease are advised to take it daily in low dose on an ongoing basis.
• Clopidogrel (Plavix), a thienopyridine, is another type of anti-platelet drug. Clopidogrel is started either immediately or right after percutaneous intervention is performed for patients with heart attacks. It is also begun after thrombolytic therapy. Patients who receive a drug-eluting stent should take clopidogrel along with aspirin for at least 1 year to reduce the risk of clots. Patients admitted for unstable angina should receive clopidogrel if they are unable to take aspirin. Clopidogrel should also be given to patients with unstable angina for whom an invasive procedure is planned. Even for conservatively treated patients, Clopidogrel should be started and continued for up to 1 year. Some patients may need to take clopidogrel on an ongoing basis.
• Glycoprotein IIb/IIIa Inhibitors. These powerful blood-thinning drugs include abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat), and lamifiban. They are administered intravenously in the hospital and are used with angioplasty and stent placement. They are proving to be helpful for ACS patients with NSTEMI (non ST-segment elevation myocardial infarction), particularly when invasive procedure is planned or patients are still unstable after receiving aspirin and clopidogrel.

Anticoagulant Drugs. Anticoagulants thin blood. They include:

• Heparin is usually begun during or at the end of treatment with thrombolytic drugs and continued for at least 2 days if not the whole time in the hospital.
• Fondaparinux (Arixtra) is a newer blood thinner that may be used, but its exact role remains unclear.
• Warfarin (Coumadin).
• Direct thrombin inhibitors, such as argatroban (Novastan), danaparoid (Orgaran), lepirudin (Refludan), and bivalirudin (Angiomax). A clear benefit for these drugs over heparin has not been shown. They also carry an increased risk for bleeding.

All of these drugs pose a risk for bleeding.

Beta blockers

Beta blockers reduce the oxygen demand of the heart by slowing the heart rate and lowering pressure in the arteries. They are effective for reducing deaths from heart disease. Beta blockers are often given to patients early in their hospitalization, sometimes intravenously. Patients with heart failure or who are at risk of going into cardiogenic shock should not receive intravenous Beta blockers. Long-term oral beta blocker therapy for patients with symptomatic coronary artery disease, particularly after heart attacks, is recommended in most patients. [For more information, see In-Depth Report #03: Coronary artery disease.]

These drugs include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc).

Administration During a Heart Attack. The beta blocker metoprolol may be given through an IV within the first few hours of a heart attack to reduce the destruction of heart tissue.

Prevention After a Heart Attack. Beta blockers taken by mouth are also used on a long-term basis (as maintenance therapy) after a first heart attack to help prevent future heart attacks.

Side Effects. Beta blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (“good”) cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. Patients with asthma, emphysema, or chronic bronchitis, should not take these beta blockers.

Patients should not abruptly stop taking these drugs. The sudden withdrawal of Beta blockers can rapidly increase heart rate and blood pressure. The doctor may want the patient to slowly decrease the dose before stopping completely.

Statins and Other Cholesterol and Lipid-Lowering Drugs

After being admitted to the hospital for acute coronary syndrome or a heart attack, patients should not be discharged without statins or other cholesterol medicine unless their LDL ("bad") cholesterol is below 100 mg/dL. Some doctors recommend that LDL should be below 70 mg/dL. [For more information, see In-Depth Report #23: Cholesterol.]

Angiotensin Converting Enzyme Inhibitors

Angiotensin converting enzyme (ACE) inhibitors are important drugs for treating patients who have had a heart attack, particularly for patients at risk for heart failure. ACE inhibitors should be given on the first day to all patients with a heart attack, unless there are medical reasons for not taking them. Patients admitted for unstable angina or acute coronary syndrome should receive ACE inhibitors if they have symptoms of heart failure or evidence of reduced left ventricular fraction echocardiogram. These drugs are also commonly used to treat high blood pressure (hypertension) and are recommended as first-line treatment for people with diabetes and kidney damage.

ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Side Effects. Side effects of ACE inhibitors are uncommon but may include an irritating cough, excessive drops in blood pressure, and allergic reactions.

Calcium Channel Blockers

Calcium channel blockers may provide relief in patients with unstable angina whose symptoms do not respond to nitrates and beta blockers, or for patients who are unable to take beta blockers.